Healthcare Provider Details

I. General information

NPI: 1275568487
Provider Name (Legal Business Name): ANNAPURNA PODURI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE CHILDREN'S HOSPITAL BOSTON
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE CHILDREN'S HOSPITAL BOSTON
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-7919
  • Fax:
Mailing address:
  • Phone: 617-355-7919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number217517
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number217517
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number217517
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: